Quality and Reg Program Assistant | SQM | Full Time (On-Site)

Job Duties and Responsibilities

• Maintain and manage the enterprise-wide quality and regulatory project tracker, including timelines, milestones, deliverables, and responsible parties.
• Track progress of quality improvement initiatives, regulatory action plans, and Joint Commission readiness activities.
• Coordinate follow-up on assigned tasks from quality committees, regulatory surveys, and executive leadership meetings.
• Identify delays, barriers, and risks in project execution and escalate issues to the Senior Director of Quality & Regulatory Affairs.
• Support implementation tracking for corrective action plans related to audits, surveys, and performance improvement initiatives.
• Maintain documentation systems related to Joint Commission readiness, CMS compliance, and other regulatory requirements.
• Organize and support documentation for accreditation surveys, mock surveys, tracer activities, and compliance audits.
• Assist in preparing materials for regulatory reviews, board reports, and executive presentations.
• Optimize timely collection and organization of evidence required for accreditation and regulatory compliance.
• Coordinate scheduling, agendas, materials, and minutes for quality, patient safety, accreditation, and population health committees.
• Track committee action items and ensure completion of assigned follow-ups.
• Maintain standardized documentation for committee structures, reporting workflows, and governance requirements.
• Support preparation of executive dashboards, reports, and presentation materials.
• Assist in maintaining quality dashboards, spreadsheets, and tracking tools used for performance monitoring.
• Assist in maintaining the incident event reporting system and associated reports.
• Compile data from multiple departments to support reporting requirements for regulatory and quality programs.
• Support documentation standardization and administrative workflows across quality and regulatory functions.
• Ensure accuracy, consistency, and version control of quality and regulatory documents.
• Serve as a communication hub between clinical quality staff, regulatory teams, ambulatory and hospital leadership, and administrative departments.
• Distribute updates related to quality initiatives, regulatory requirements, and accreditation readiness activities.
• Facilitate timely communication of deadlines, deliverables, and regulatory requirements across departments.

Job Requirements

Required Education

Associates or Bachelors Degree in Healthcare Administration, Business Administration, Public Health, or related field

Required Work experience

• 2-5 years of experience in healthcare administration, project coordination, quality support, regulatory compliance, or related field.
• Experience in a hospital, health system, or ambulatory care setting strongly preferred.
• Experience supporting quality improvement, accreditation, or regulatory programs is a plus.

Required knowledge, skills, and abilities

• Strong organizational and project management skills.
• Ability to track multiple projects, deadlines, and priorities simultaneously.
• High attention to detail and accuracy in documentation and reporting.
• Strong communication and interpersonal skills.
• Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint) and project tracking tools.
• Ability to work effectively with clinical and non-clinical stakeholders.
• Understanding of healthcare operations, quality programs, or regulatory environments preferred.
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Success Measures

• Timely and accurate tracking of quality and regulatory projects.
• Effective coordination of accreditation and regulatory documentation.
• Completion and follow-up of committee and action items.
• Improved organization and efficiency of quality and regulatory workflows.
• Reduction of administrative burden on clinical quality and leadership teams.
• Support of successful Joint Commission and regulatory survey readiness

Organizational Expectations

• Provides a positive and professional representation of the organization.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.
• Maintains hospital standards for a clean and quiet environment.
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope-of-practice or job role.
• Participates in ongoing quality improvement activities.
• Maintains compliance with organization's policies, as well as established practices, protocols, and procedures of the position, department, and applicable professional standards.
• Complies with organizational and regulatory policies for handling confidential information.
• Demonstrates excellent customer service through their attitude and actions, consistent with the standards contained in The Gritman Way.